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Special Exposure Cohort Petition Us. Department nt of Health and Human: Services|
under the Energy Employees Occupational Centers for Disease Control and Prevention
liiness Compensation Act National institute for Occupational Safety and Health

‘OMB Number: 0820-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Pago 4 of 7)

Name of DOE or AWE Facili ETE -Atom/es
Locations at the Facility relevant to this petition:

SANTA Susawh Field dab Akese lv All AREAS

List Job titles and/or Job dutles of employees included In ‘the class, In ‘addition, you can list by
name any Individuals other than petitioners Identified on this form who you belleve should be

included In this class: AdL rchacl ag AL FCO.
7 a

Employment Dates relevant to this petition: “
” De sealt _tresedt

sat  f/P@5 5 end

Stat _ End. a

Start End. __

Is the petition based on one or more unmonitored, unrecorded, or Inadequately monitored or
recorded exposure incidents?: SkYes Q No

If yes, provide the date(s) of the incident(s) and a complete description (attach additional pages
as necessary);

Lgee. Team Bepe of 18S

Moi Roe film. Badges

nbidens, Ath noniteds place Us geceve Mp? loid, 5g, of lo

Eiltens 04 The Kadinkiia sfobsge DLCs.
Eek dl of Hetadistuchda selegsed faaivg die
petial meltdown wt the Sodium Keone Ex pealmen
Missing Moncleeiag, kecdids Fee the £y ype BS
Biting of Eso, FeedsEt § jy LBe@ © Sa
(hw Pho RECOK as
Ah. Hi blees wordestized ch Mhonttoe. A haage, RANGE OF
pbeticudsdbes.s Evidenet 8F Ys. jacopipletely GRE Eye .
be Atiwat Ae Sampling dekiig Ue YEpes. All (OF eRibiotf
Shetty hte deca pen adel oF Spits altho Hiei 7
MenttoehtAg Wwlls, raced gee dicath
Ne Sckl oh. inter Samplig Fe R TRICILIN

Go to P:

Name or Social Security Number of First Petitioner.



Petition 693
Reference List
November 16, 2007

15. United States Environmental Protection Agency, Memorandum from Gregg D.
Dempsey, Chief, dated July 28, 1989

16. Department of Health Services letter to Dr, Robert Goldsmith, U.S. DOE Office of
Epidemiology and Health Services dated October 5, 1990

17. Los Angeles Daily News, dated June 21, 2005, “Higher Tritium Levels Found in
Water at Field Lab.

18, Rocketdyne Worker Health Study Summary

19. Los Angeles Times, July 12, 2001, “Ex-Rocketdyne Employees to Be Paid for
Tlinesses,

20. Studies of Atomics Bomb Survivors, Understand Radiation Effects, August 1, 1990

21. Exerpts from a report provided by Norm Riley, Chief California DISC regarding the
Old Sodium Burn Pit.

22. An Incidence report from Atomics international dated October 27, 1964
23. Acase file for Daniel Kurowski, a radioactive materials packer and handler

24. Acase for Vern Burgett, an on-site fireman who routinely extinguished uranium
fires,

25. A DVD of the 2007 hearings on SB 990 the History Channe} documentary on the
partial meltdown of the SRE,

26. ADVD imiiler, Rockets Red Glare, on the human toll of the Cold War Era

27. Aerial Radiological Surveys of ROCK WELL INTERNATIONAL FACILITIES,
Canoga Pask, California, dated June and July 1978

28. The DOE Tiger Team Report for the SSFL Lab, dated 1989.



Special Exposure Cohort Petition U.S. Department of Health and Human Services
under the Energy Employees Occupational Centers for Disease Control and Prevention
illness Compensation Act National Institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 05/91/2007
Special Exposure Cohort Petition — Form B Page 3 of 7
Labor Organization Information —- Complete Section D ONLY if you area labor organization.
D.1 — Laber Organization Information:
Name oKQraanizatin MV A
Position of Centact Person
D.2 Name of Petition Representative:
D3 Address of Paton Represent
Street Apt # P.O. Box
City ~ Zip Code
D4 Telephone Number of Petition resentative: ( 1 > ce
D.5 Email Address of Petition Representative:
0.6 Period during which labor organizationyepresented employees covered by this petition
(please attach documentation): Start End
D.7 Identity of other labor organizations that mayxepresent or have represented this class of
employees (if known):
we
Go to Part E.

Name or Social Security Number of First Petitioner:



key sed Moff

U.S, Department of Health and Human Services
enters for Disease Contro! and Prevention
National institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 05/31/2007
Page § of 7

Special Exposure Cohort Petition
under the Energy Employees Occupational
liness Compensation Act

Special Exposure Cohort Petition — Form B
Basis for Proposing that Records and Information are Inadequate for Individual Dose -—
Coniplete Section F,

Complete at least one of the following entries in this section by checking the appropriate box and providing
the required information related to the selection. You are not required to complete more than one entry.

F.4 gw (We have attached either documents or statements provided by affidavit that indicate that
“radiation exposures and radiation doses potentially incurred by members of the proposed class,
that relate to this petition, were not monitored, either through personal monitoring or through area

monitoring.
(Attach documents and/or affidavits to the back of the petition form.)

Describe as completely as possible, to the extent it might be unclear, how the attached
documentation and/or affidavit(s) indicate that potential radiation exposures were not monjtored.

= Wylen vas bi sthtet Loaet Document S-damping padsoadid ?
BBE AL  ebeclakitioy oF. on
the OPH Bie. BUEN Pits the dadeceymented CeflepGES
FEI The she, °ligek firm Keyset ¢ pay Crogg Rempsey
Cher, IS9 CAVING suphopek Sasi meter badges, lack sf Lacknas,
beeper tip phoma pela, tit phapok. LBM 4 bp) JeSFS,
Lk oF sencteetpppW oF he Whole STe-
Aethl hada loiienl SHUCG shows fons 2F prdionct iy 0 wtste
shied in ves by Bb 142 -tah buds of BI37 + C260
F.2 se |) We have attached either documents or statements provided by affidavit that indicate that
radiation monitoring records for members of the proposed class have been lost, falsified, or
destroyed; or that there is no information regarding monitoring, source, source term, or process
from the site where the employees worked.

(Attach documents and/or affidavits to the back of the petition form.)

Describe as completely as possible, to the extent it might be unclear, how the attached
: documentation and/or affidavit(s) indicate that radiation monitoring records for members of the

, proposed class have been lost, altered illegally, or destroyed.
' Becensed Lune Litas Sk Qase-NHennrs 4 fachek x

Chitek. oF bio Heniye waste —Me mepieng RECCRAS

bbb Asal R&EOLAS |
(een Bitset a2 Pikeman Myjssing PALMS MEDTSAG
Raced s

Part F is continued on the following page,

Name or Social Security Number of First Petitioner:



November 16, 2007

SEC Petition 093

Office of Compensation Analysis and Support

NIOSH

4676 Columbia Parkway, MS-C-47

Cincinnati, Oh 45226

Re: Revision for SEC Petition 093 dated Noveriber, 2007
Dear Representative:

Please accept a revision for the above mentioned petition,

Sincerely yours,

BIVE
0 ECEIY

HOY 19 aod

Kecruentonnemennnenenane

Lacengsneciznromm—



RESOURCE LIST
PETITION 093
NOVEMBER, 2007

1. United States District Court Norther District of California, Natural Resources
Defense Council, Inc., Committee to Bridge the Gap, and City of Los Angeles, Plaintiffs,
y. Department of Energy, Spencer Abraham, Secretary, Department of Energy, and
Camile Yuan-SOO HOO, Manager, Nationat Nuctear Security Administration, Oakland
Operations Office, Defendants. Dated May 2, 2007

2. United States District Court Centrai District of California Western Division, Lawrence
O'Connor, etal, v, Boeing North American, Inc,, et al., Defendants filed February 4,
2004 Declaration of © , and the declaration of

3. Letter from , Assemblymember, 41" District dated May 4, 2007

4, Statement of the Honorable John N. Hostetler, dated December 5, 2006

§. Rocketdyne Inter-Office Letters Only, dated 1 March 1960

6. Page 15 of Ecology and Environment, Inc., dated July 19, 1989 regarding the Sodium
Burn Pit.

7. Nuclear Operations at Rockweltl’s Santa Susana Field Laboratory-A Factual
Perspective, dated December 20, 1989.

8. Memo from EPA dated December 2003

9. Letter from to Congressman Elton Gallegly dated March 1, 2006
regarding EEOICPA Washington Hearings. ,

10. EUR. 2243 dated May 9, 2007

11. EPA Update regarding the SSFL Off-Site Sampling Program, dated July, 1995

¥2. Letter to Larry Elliott, Director of NIOSH BEGICPA, dated June 4, 2006

43. Atomics International memo regarding a uranium fire dated May 19, 1967

14, Letter from the Cancer Surveillance Section to”

Environmental Epidemiology and Toxicology Branch regarding cancer incidence rates in

five Los Angeles County census tracts closest to the SSFL, dated
October 10, 1990.



Keysed -0 FD

[Special Exposure Cohort Petition U.S. Department of Health and Human Services |
under the Energy Emp oyees Occupational Centers for Disease Control and Prevention
1 iness Compensaton Act National institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition — Form B Page 6 of 7

F.3. Q I/We have attached a report from a health physicist or other individual with expertise in
radiation dose reconstruction documenting the limitations of existing DOE or AWE records on
radiation exposures at the facility, as relevant to the petition. The report specifies the basis for
believing these documented limitations might prevent the completion of dose reconstructions for
members of the class under 42 CFR Part 82 and related NIOSH technical implementation
guidelines.

(Attach report to the back of the petition form.)

F.4. Q IWehave attached a scientific or technical report, Issued by a government agency of the
Executive Branch of Government or the General Accounting Office, the Nuclear Regulatory
Commission, or the Defense Nuclear Facilities Safety Board, or published in a peer-reviewed
journal, that identifies dosimetry and related information that are unavailable (due to either a lack
of monitoring or the destruction or loss of records) for estimating the radiation doses of
employees covered by the petition.

(Attach report to the back of the petition form.)
Go to Part G.

gnature of P. ns} Submitti
All Petitioners should sian and date the petition. A maximum of three persons may sign the petition.

—! —  Aefe-0'7
Signature Date
Signatur Date
Signature : Date
Notice: Any person who knowingly makes any false statement, misrepresentation, concealment of

fact or any other act of fraud to obtain compensation as provided under EEOICPA or who
knowingly accepts compensation to which that person is not entitled is subject to civil or
administrative remedies as well as felony criminal prosecution and may, under appropriate
criminal provisions, be punished by a fine or Imprisonment or both. | affirm that the informatio!
provided on this form is accurate and true.

Send this form to: SEC Petition
Office of Compensation Analysis and Support
NIOSH
4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

If there are additional petitioners, they must complete the Appendix Forms for additional petitioners.
The Appendix forms are located at the end of this document.

Name or Social Security Number of First Petitioner:



x

Peyised Novem ber, 2007

Special Exposure Cohort Petition U.S. Department of Health and Human Services |
under the Energy Employees Occupational Centers for Disease Control and Pravention
liness Compensation Act National Institute for Occupatlionat Safety and Heatth
OMB Number; 0920-0639 Expires: 05/31/2007
Special Exposure Cohort Petition —~ Form B Page 2 of 7

Survivor Information — Complete Section G if you are 4 Survivor or representing a Survivor,

B.1. Name of Survivor:

Mr/Mrs./Ms. First Name Middle Initial Last Name
B.2 Social Security Number of Survivor: ne
B.3 Address of Survivor:

Street Apt # P.O. Box

City State Zip Code
8.4 Telephone Number of Survivor: L
B.5 Email Address of Survivor:

8.6 —_ Relationship to Employee: Q Spouse Q Son/Daughter Q Parent
OQ Grandparent Q Grandchild '
Go to Part C.

Employee Information — Complete Section C UNLESS you are a labor organization.

C.1 Name of Employee; Lae

LX, _~ —e
Mr./Mrg./Ms,} First Name Middle Initial Last Name
C.2__ Former Name of Employee (¢.g., maiden name/legal name change/other): _,

MriMrs@Ms) First Name Middle Initial Last Name
C.3 Social Security Number of Employee: a
C.4 Address of Employee (if living):

Street Apt # . P.O, Box

City State” ~ Zip Code
C5 Telephone Number of Employee:
C.6 Email Address of Employee:

C7 Employment Information Related to Petition:
C.7a Employee Number (if known):

C.7b Dates of Employment: stat __/763 End : .
C.7¢ Employer Name: Atomies Inter NWational
C.7d Work Site Location: Sata sasAnaegreld kab

C.7e Supervisor's Name: _ —

Go to Part E.

Name or Social Security Number of First Petitioner: